Your Volume Is Up. Why Aren’t Your Margins?

Outpatient surgical volumes are projected to reach 109.6 million cases by 2033 — an 18% increase over 2023 levels. In most markets, ASC schedules are as full as they’ve ever been. New procedures are coming out of the hospital setting and into the ambulatory environment. By every headline metric, the ASC industry is thriving.

So why are so many administrators sitting in their offices staring at margin reports that don’t match the activity they see in the OR?

‘Financial sustainability will become the defining challenge,’ Leann Ackley, Revenue Cycle Supervisor at Tampa General Hospital, told Becker’s at the close of 2025. ‘While payers continue to push procedures into ASCs, ASCs must carefully evaluate whether the cases they accept make economic sense.’ That is a precise and uncomfortable truth that not enough ASC leaders are confronting directly.

More Volume Is Not the Same as More Revenue

The growth story for ASCs in 2026 is real — but it comes layered with rising costs, payer pressure, and operational complexity that can quietly erode the financial gains from volume growth. Supply and implant costs continue to escalate. Staffing costs — particularly for anesthesia and nursing — remain elevated. And reimbursement rates, despite the 2.6% Medicare update, continue to lag behind the true cost trajectory for many centers.

The result is what some operators are calling a ‘reimbursement hangover’: cases are added, capital is deployed, staffing ramps up — and then payment delays, underpayments, and contract mismatches surface. The OR is busy. The bank account doesn’t reflect it.

Understanding the mechanics of this gap — and closing it systematically — is what separates ASCs that grow profitably from those that grow themselves into a financial problem.

15–28%  — estimated EBITDA erosion for surgical ASCs with unresolved implant charge capture and payer-variance gaps, according to 2026 RCM industry analysis.

The Three Layers of Margin Erosion

Layer 1: Payer contract misalignment. Most ASCs operate under payer contracts negotiated years ago — often before significant service line expansion, before the 2026 CPL additions, and before the center’s current case volume and complexity profile existed. Contracts that don’t reflect your actual procedure mix, acuity level, or current CMS benchmarks are systematically underpaying you. The problem is rarely visible in aggregate AR data. It shows up only when someone does a line-by-line realization rate analysis by payer and procedure code — and most centers don’t have the bandwidth to do that consistently.

Layer 2: Revenue cycle infrastructure gaps. Lean RCM staffing is a feature of the ASC model — until the payer environment becomes complex enough that lean becomes exposed. In a stable, low-acuity case environment, a small billing team can manage effectively. In a 2026 environment with 560 new CPL procedures, varying commercial payer update timelines, new implant documentation requirements, and evolving prior authorization policies, single-threaded revenue cycle functions create systematic vulnerability. Denials become harder to stay ahead of. Underpayments are more difficult to identify. Performance insights surface slowly, if at all.

Layer 3: Case mix economics. Not all volume is created equal. Payers continue to push cases into ASCs specifically because it reduces their costs — which doesn’t automatically mean it improves your margin. A high volume of lower-reimbursing cases that consume comparable OR time and supplies as higher-acuity procedures can dilute your overall margin even as your total case count climbs. Centers that don’t regularly analyze their case mix by specialty, payer, and net revenue per case are making scheduling decisions without the financial data to support them.

What the Best-Performing ASCs Are Doing Differently

The ASC leaders navigating this environment successfully share a few consistent practices that separate them from centers stuck in the volume-without-margin trap:

•     They review payer contracts proactively — not just at renewal. Any significant service line expansion, CPL addition, or case volume change is treated as a trigger for contract review.
•     They track net revenue per case by payer and by procedure — not just total collections. This is the KPI that actually tells you whether your volume is profitable.
•     They have a denial root-cause process — not just a denial appeal process. There’s a meaningful difference between chasing denials after they happen and engineering the billing workflow to prevent them upstream.
•     They treat quality data as a strategic asset. Outcome data, patient satisfaction scores, and complication rates are increasingly the most powerful leverage an ASC has in payer negotiations. Centers that collect and present this data well negotiate from a position of strength.
•     They partner with management expertise that has seen the patterns across centers. The financial pressures hitting your ASC are hitting every ASC — but the solutions look different depending on your specialty mix, payer environment, and operational profile.

The Honest Assessment

The ambition to grow your surgery center is right. The growth opportunity in the ASC space is genuine and durable. But growth without disciplined revenue cycle management, contract alignment, and case mix analysis is how a thriving clinical operation ends up in a financial squeeze — and leadership doesn’t fully understand why until months after the erosion began.

The question isn’t whether your center can grow. It’s whether the financial infrastructure underneath that growth is strong enough to actually capture the margin your OR is earning.

$4,425  — projected average net revenue per ASC case in 2026. Your center’s actual number by payer and procedure is the most important benchmark you should know right now.